Medical Claims Processor – Reimbursement

Job Purpose: 

• Adjudication and processing of reimbursement claims in accordance to policy terms and conditions in a timely manner, applying sound medical judgment based on best practice during assessment of claims.
• Identification of trends related to abuse and fraudulent claims.
• Interpret and process claims using knowledge of ICD codes, billing, benefits, and company policies.
• To respond to and liaise as required with AXA policy holders, insurance brokers and network providers in a professional and courteous manner.

 
Main Responsibilities:

• Process reimbursement claims following SOPs, applying sound medical judgment based on best practice and in accordance with the conditions & terms of the policies;
• Handle relationships with clients and brokers regarding reimbursement claims by asking for additional information whenever required, by explaining the details of the settlements (i.e. application of the deductible and coverage, justify rejections and uncovered expense);
• Process the claims within a reasonable time frame within SLA and meeting the set KPIs;
• Minimize conflicts with clients whilst applying strictly the policy conditions;
• Adjudicate and approve claims within the authority limits set and to refer cases to the claims manager for approval where authority limits are exceeded.